HESI RN
Adult Health 1 HESI
1. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
- A. Avoid using friction when cleaning around the CVAD insertion site.
- B. Use the push-pause method to flush the CVAD after giving medications.
- C. Obtain an order from the healthcare provider to change the CVAD dressing.
- D. Position the patient’s face away from the CVAD during injection cap changes.
Correct answer: B
Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.
2. Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:
- A. Hypotension.
- B. Thick, coarse skin.
- C. Deposits of adipose tissue in the trunk and dorsocervical area.
- D. Weight gain in arms and legs.
Correct answer: C
Rationale: In Cushing's syndrome, the characteristic features include central obesity with deposits of adipose tissue in the trunk and dorsocervical area, often referred to as a 'buffalo hump.' Hypotension (Choice A) is not typically associated with Cushing's syndrome; instead, hypertension is more common. Thick, coarse skin (Choice B) is seen in conditions like hypothyroidism, not specifically in Cushing's syndrome. Weight gain in the arms and legs (Choice D) is not a typical finding in Cushing's syndrome; rather, weight gain is more prominent in the central areas of the body.
3. Following admission for cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?
- A. Encourage oral electrolyte solution intake
- B. Assist the child to a recumbent position
- C. Contact their healthcare provider immediately
- D. Provide a quiet time by holding or rocking the toddler
Correct answer: C
Rationale: If a child with tetralogy of Fallot becomes pale, cool, and lethargic, these symptoms may indicate a hypoxic episode or worsening condition. It is crucial to contact the healthcare provider immediately for further evaluation and management to ensure the child's safety and well-being. Option A is incorrect because electrolyte solution intake is not the immediate action needed for these symptoms. Option B is incorrect as positioning alone may not address the underlying issue. Option D is incorrect as providing a quiet time is not appropriate if the child is experiencing concerning symptoms that require prompt medical attention.
4. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Vastus lateralis muscle
- D. Dorsogluteal muscle
Correct answer: B
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.
5. The healthcare provider is caring for a client with diabetes insipidus. Which finding indicates that the treatment is effective?
- A. Urine output is decreased.
- B. Thirst is decreased.
- C. Weight loss is observed.
- D. Urine specific gravity is within the normal range.
Correct answer: D
Rationale: In diabetes insipidus, the body loses excessive amounts of water, leading to diluted urine with low specific gravity. Therefore, when the urine specific gravity is within the normal range, it indicates that the kidneys are properly concentrating urine, which is a sign of effective treatment for diabetes insipidus. Choices A, B, and C are incorrect because in diabetes insipidus, there is polyuria (excessive urination), persistent thirst due to fluid loss, and potential weight loss due to fluid imbalance, so these findings would not indicate effective treatment.